Health inspection·July 27, 2021

F600§483.12(a)(1) FREEDOM FROM ABUSE, NEGLECT, AND EXPLOITATION The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; The facility failed to ensure 1 of 3 residents (Resident 1) was kept free from abuse when respiratory therapist A (RT A) was very rough when providing care to Resident 1. This failure had the potential to have a negative impact on residents’ physical and emotional well-being. Findings: During a review of a written statement by licensed vocational nurse B (LVN B) during the facility’s internal investigation, dated 3/31/2020, indicated LVN B had witnessed RT A wheeling Resident 1, in a wheelchair down the hallway. When RT A and Resident 1 arrived at Resident 1’s ventilator (machine used to help a person to breath), RT A yanked on Resident 1’s tracheostomy (trach, tube entering airway to bypass nose and mouth) to try and reconnect him to the vent. RT A looked upset, and LVN B tried to intervene, and told RT A to step back, because she was afraid RT might hurt Resident 1. The written statement also indicated that LVN B observed RT A aggressively grabbing Resident 1’s hands. The written statement indicated charge nurse C (CN C) had entered the room to help and intervened. The written statement indicated CN had told RT A to step back and take a break. The written statement indicated Resident 1 was very upset the entire time and was trying to pull away from RT A. During a review of the facility’s Internal Investigative Summary (IIS) dated 4/3/2020, the IIS indicated LVN B witnessed RT A provide inappropriate (rough) direct care to Resident 1. The conclusion of the IIS was that RT A did provide inappropriate care to Resident 1. During an interview with the administrator (ADM) and director of nursing (DON) on 3/5/21 at 9:04 a.m., the ADM and DON stated they were not working at the facility when the alleged incident was reported. During a review of the facility’s undated policy “Abuse,” indicated, residents will be free from verbal, sexual, physical, emotional/mental abuse…corporal punishment…at all times. The facility’s failure to ensure Resident 1 was free from abuse had direct relationship to the health, safety, or security of residents.